DOI: http://dx.doi.org/10.5007/1980-0037.2014v16s1p13
original article
Licence Creative Commom CC
RBCDH
1 Federal University of Santa Catarina. Graduate Program in Physical Education. Florianopolis, SC, Brazil.
2 University of Pernambuco. Graduate Program in Physical Education. Recife, PE, Brazil.
3 University of Sao Paulo. Gra-duate Program in Public Health Nutrition, São Paulo, SP, Brazil.
Received: 23 January 2014 Accepted: 22 March 2014
Efectiveness on physical activity indicators
of an intervention delivered to high school
students
Efetividade em indicadores de atividade física de uma
intervenção com estudantes do ensino médio
Giovâni Firpo Del Duca1
Mauro Virgílio Gomes de Barros2
Kelly Samara Silva1
Leandro Martin Totaro Garcia3
Jorge Bezerra1
Markus Vinicius Nahas1
Abstract– High schools represent a favorable environment for the development of
in-terventions to increase physical activity because they reach a large number of teenagers. he goal of the study was to determine the efectiveness of an intervention to promote physical activity among high school students (through the ‘Saúde na Boa’ project) through assessing the stages of behavior change and the practices of muscle-strengthening exer-cise and active commuting. he present study comprised a randomized and controlled intervention conducted in Recife and Florianopolis, Brazil, during 2006. Dependent vari-ables included active commuting (cutof values: ≥1 and ≥5 days per week), the practice of muscle-strengthening exercises (cutof values: ≥1 day per week and the recommended level of physical activity), and behavioral changes regarding physical activity. Of the 2,155 students included in the baseline data, 989 were evaluated in the post-intervention period (45.9%). In comparison with the control group, the intervention group signii-cantly increased the practice of active commuting to school on ≥ 1 day per week (80.5% vs. 86.8%, p<0.001) and ≥ 5 days per week (64.3% vs. 71.9%, p<0.001), the practice of muscle-strengthening exercises on ≥ 1 day per week (41.4% vs. 46.0%, p=0.017), and the achievement of the recommended levels of exercise (28.9% vs. 35.0%, p=0.002). he intervention group reached higher stages of change in physical activity behavior compared with controls (p = 0.004). he ‘Saúde na Boa’ project efectively enhanced the practices of active commuting to school and muscle-strengthening exercises and resulted in an increased physical activity status.
Key words: Adolescent; Intervention studies; Motor activity; Muscle Strength; Transport.
Efectiveness of an intervention in physical activity Del Duca et al.
INTRODUCTION
he practice of physical activity in adolescence can improve several health indicators, stimulate physical growth and development, and prevent
im-portant chronic diseases, such as obesity and depression1. In addition, a
physically active lifestyle at this developmental stage may increase the
probability of maintaining this habit throughout adulthood2. Nonetheless,
a considerable number of Brazilian teenagers do not perform the
recom-mended levels of physical activity3. In addition, the prevalence of obesity
has increased signiicantly in the last 20 years and, at present, one out of
every ive Brazilian teenagers exhibits this health risk condition4.
Research on physical activity has devoted special attention to aerobic activities, particularly when practiced in leisure. Other forms of physical activity that are equally important to adolescent health, such as the prac-tices of active commuting and muscle-strengthening exercises, have been less explored in the literature. In this respect, active commuting is known to signiicantly contribute to daily physical activity and to decrease the
propensity towards obesity5, while muscle-strengthening exercises build
muscle and elicit an increase in lean body mass1.
Social support measures throughout adolescence are clearly
associ-ated with smaller declines in physical activity6. In this sense, the school is
recognized as an important place for the development of interventions to
promote regular physical activity7, and the achievement of adequate levels
of physical activity can be facilitated by integrating the entire school system, including teachers, students, families, administrators, and public policies.
Although schools can enhance physical activity in adolescents, relevant studies on this topic are still lacking, particularly in countries with low and average income. hus, the aim of this study was to assess the efectiveness of an intervention to promote physical activity (through the Saúde na Boa project) on the stages of behavior change and the practices of muscle-strengthening exercises and active commuting by high school students.
METHODS
he study consisted of a randomized, controlled, and cross-cultural interven-tion implemented during the school year (March to December) of 2006. he Saúde na Boa project to stimulate physical activity and healthy eating habits was conducted with students who were undertaking public high school even-ing courses in two Brazilian cities – Recife and Florianopolis. hese cities were selected based on the environmental and sociocultural contrasts between the two at the time of the study. Indeed, these contrasts are still evident to date: considering the 26 state capitals and the Federal District, Florianopolis ranks
irst in the Human Development Index, whereas Recife is in position thirteen8.
re-sources. Strategic actions developed during the intervention included the dissemination of educational information via a website, the preparation of thematic posters and newsletters for classroom discussion, the creation of bicycle racks, the distribution of seasonal fruits, the delivery of physical activity kits, the organization of special weekend activities, such as hiking and cycling, and the presentation of lectures for teachers, technicians, stu-dents, and parents/guardians. he logic model and a complete description
of the activities provided by the project have been previously reported9.
Twenty schools were randomly selected (10 in each city) and paired ac-cording to size and geographical location. Half of the schools were assigned to each group (control and experimental). Students aged 15-24 years who were enrolled in high school evening courses at the selected schools were invited to participate. Detailed information about the sampling process
has been previously described9.
For data collection, a speciic and previously validated questionnaire,
designated Saúde na Boa, was used10. he instrument was collectively
ap-plied in the classroom by a team of graduate students in Physical Education, who were adequately trained by the study supervisors.
he outcomes of the study involved three physical activity indicators: active commuting to and from school, the practice of muscle-strengthening exercises, and the stage of physical activity behavior change. Active commut-ing was assessed with the followcommut-ing question: “Durcommut-ing a typical week, how many days do you walk or pedal to and from school or work?” his outcome was evaluated using cutof values of ≥ 1 and ≥ 5 days per week. he practice of muscle-strengthening exercises was evaluated with the question: “During a typical week, how many days do you perform exercises to improve muscle tone and strength, such as weight liting or gymnastics (e.g., support on the ground or hanging on the bar)?” Similarly, two cutof values were used for this activity: the practice of muscle-strengthening exercises on ≥ 1 day per week and adherence to the recommended practice of resistance exercises on two or more days per week for individuals under 17 years of age or on
three or more days per week for those aged 18 years or older11. he stages
of behavior change arising from the trans-theoretical model were used to
deine the efects on physical activity12. For this outcome, we used the
Efectiveness of an intervention in physical activity Del Duca et al.
Descriptive statistics included absolute frequencies (n) and relative frequencies (%). he efectiveness of the Saúde na Boa project was assessed considering the intention-to-treat principle (data input using the Last Ob-servation Carried Forward imputation method) considering only the data collected (i.e., data from students who inished the survey). Fisher’s exact test was used for comparisons between the control and intervention groups. he comparisons among the control group (baseline vs. postintervention) and the intervention group (baseline vs. postintervention) were performed using the McNemar test and the Stuart-Maxwell test for marginal homo-geneity, for dichotomous and polytomous variables, respectively.
Data were adjusted with binary logistic regression (for the dichoto-mous variables) and multinomial logistic regression (for the polytodichoto-mous variables). Multinomial regression was performed because the stages of behavior change did not meet all conditions of the ordinal regression and violated the assumption of the proportional odds ratio. In view of the so-ciodemographic diferences between the two groups in the baseline, other indicators, such as gender, age, ethnicity, occupation, and school location (classiied as shown in Table 1) were included as potential confounders. For statistical modeling, we adopted the strategy of backward selection with the inclusion of all sociodemographic variables. In addition, we adopted a critical level of p ≤ 0.20 for permanence in the model. he results were expressed as odds ratios (OR) and conidence intervals of 95% (95% CI).
he study was approved by the Ethics Committee of the Federal Univer-sity of Santa Catarina (Universidade Federal de Santa Catarina - Protocol N. 031/2005) and by the Mother and Child Institute of Pernambuco (Instituto Materno Infantil de Pernambuco - Protocol N. 587/2005).
RESULTS
he baseline data of the Saúde na Boa project included 2,155 students, the majority of whom comprised non-Caucasian, unemployed, female high school students in Florianopolis. here were signiicant diferences between the control and intervention groups of this sample. Of these 2,155 students, 989 participated in the postintervention period (45.9%). Except for occupa-tion, most of these students exhibited a sociodemographic proile similar to that of the baseline group, without signiicant diferences between the control and intervention groups. Detailed information about the sociode-mographic proiles of the students is shown in Table 1.
Table 2 presents the efectiveness of the intervention on physical activity indicators using the intention-to-treat analysis. Except for the practice of active commuting ≥1 day per week, no signiicant diference was found for these indicators when the control and intervention groups were compared at baseline. Following the intervention, the intervention group exhibited the greatest number of students practicing active commuting ≥ 1 day per week and ≥ 5 days per week, in comparison with the control group; the interven-tion group also practiced more muscle-strengthening exercises on ≥1 day per week and a higher number achieved the recommended levels of muscle-strengthening exercises. In addition, we observed a signiicant increase in the number of students at advanced stages of change in physical activity behavior following intervention, in comparison with the control group.
For the control group, the comparison between the baseline and the postintervention period (Table 2) revealed a decrease in the number of students who practiced active commuting on ≥ 5 days per week and an increase in the number of those belonging to more advanced stages of behavior change.
For the intervention group, the comparison between the baseline and the postintervention period indicated that the intervention signiicantly increased the practice of muscle-strengthening exercises on ≥1 day per week and enabled the achievement of the muscle-strengthening exercise amounts recommended for a healthy lifestyle. In addition, the efective-ness determined using the collected data (Table 3) was very similar to that observed using the intention-to-treat principle (Table 2).
Table 1. Sociodemographic proile of public high-school students enrolled in the Saúde na Boa project in Florianopolis (State of Santa Catarina) and Recife (State of Pernambuco), 2006.
Variables
Baseline (n = 2155) Postintervention (n = 989) Control Intervention
p-value Control Intervention p-value
n % n % n % n %
Gender
Female 576 52.8 619 58.6 0.007 295 57.5 295 62.6 0.104 Male 515 47.2 437 41.4 218 42.5 176 37.4
Age (years)
14-16 314 28.7 228 21.5 0.001 66 12.8 43 9.1 0.083 17-19 494 45.0 527 49.8 269 52.2 241 50.8
20-24 288 26.3 304 28.7 180 35.0 190 40.1 Ethnicity (auto reported)
Caucasian 488 44.7 423 40.2 0.036 211 41.1 174 37.1 0.213 Other 605 55.3 630 59.8 302 58.9 295 62.9
Employeda (auto reported)
No 565 51.8 573 54.4 0.243 237 46.7 193 40.8 0.071 Yes 525 48.2 480 45.6 271 53.4 280 59.2
School location
Florianopolis 564 51.5 592 55.9 0.042 268 52.1 262 55.3 0.338 Recife 532 48.5 467 44.1 247 47.9 212 44.7
Efectiveness of an intervention in physical activity Del Duca et al.
Table 2. Efectiveness analysis of the Saúde na Boa project using the intention-to-treat analysis of physical activity indicators among public high-school students in Florianopolis (State of Santa Catarina) and Recife (State of Pernambuco) in 2006.
Variables
Baseline Postintervention
p-value Control Intervention Control Intervention
n % n % n % n %
Control vs. Interven-tion (Baseline) Control vs. Interven-tion (Postinter-vention) Control vs. Control (Baseline vs. Postinter-vention) Intervention vs. Intervention (Baseline vs. Postinterven-tion) Active commuting
≥ 1 day/week 873 81.1 888 85.5 877 80.5 909 86.8 0.003 < 0,001 0.654 0.182 Active commuting
≥ 5 days/week 731 67.9 727 70.0 700 64.3 753 71.9 0.152 < 0,001 0.005 0.113 Practice of muscle-strengthening exercises
≥ 1 day/week 427 39.4 427 41.0 451 41.4 483 46.0 0.230 0.017 0.103 < 0,001 Achievement of the recommended levels of muscle-strengthening exercises
Yes 299 27.6 308 29.6 315 28.9 367 35.0 0.162 0.002 0.315 < 0,001 Stages of change in physical activity behavior
Pre-contem-plation
77 7.1 60 5.8 102 9.4 65 6.2 0.114 0.004 0.045 0.138 Contemplation 196 18.2 156 15.1 205 18.8 162 15.4
Preparation 227 21.0 222 21.5 223 20.4 208 19.8 Action 199 18.4 186 17.9 198 18.2 212 20.2 Maintenance 380 35.2 411 39.7 363 33.2 402 38.3
Notes: p-values for the comparisons between the control and intervention groups were derived from the Fisher’s exact test. p-values for the comparisons among the control and intervention groups were derived from the McNemar test (dichotomous variables) and the Stuart-Maxwell test for marginal homogeneity (polytomous variables).
Table 3. Efectiveness of the intervention considering only data collected from the Saúde na Boa project on the physical activity indicators of public high-school students in Florianopolis (State of Santa Catarina) and Recife (State of Pernambuco) in 2006.
Variables Baseline Postintervention p-value Control Interven-tion Control Interven-tion
n % n % n % n %
Control vs. Interven-tion (Baseline) Control vs. Intervention (Postinter-vention) Control vs. Control (Baseline vs. Postint-ervention) Intervention vs. Intervention (Baseline vs. Postintervention) Active commuting
≥1 day/week 873 81.1 888 85.5 407 80.0 415 88.5 0.003 < 0,001 0.654 0.182 Active commuting
≥5 days/week 731 67.9 727 70.0 311 61.1 341 72.7 0.152 < 0,001 0.005 0.113 Practice of muscle-strengthening exercises
≥1 day/week 427 39.4 427 41.0 206 40.5 215 45.6 0.230 0.058 0.103 < 0,001 Achievement of the recommended levels of muscle-strengthening exercises
Yes 299 27.6 308 29.6 143 28.1 170 36.1 0.162 0.005 0.315 < 0,001 Stages of change in physical activity behavior
Pre-contempla-tion
77 7.1 60 5.8 56 11.0 32 6.9 0.114 0.003 0.045 0.138 Contemplation 196 18.2 156 15.1 95 18.7 77 16.5
Preparation 227 21.0 222 21.5 119 23.4 83 17.8 Action 199 18.4 186 17.9 87 17.1 106 22.8 Maintenance 380 35.2 411 39.7 151 29.7 168 36.1
Tables 4 and 5 show the efects of the Saúde na Boa project on physical activity indicators. In Table 4, the efectiveness results using the intention-to-treat principle revealed that the participants who received intervention practiced more active commuting on ≥ 1 day per week and ≥ 5 days per week than those students in the control group. In addition, these postintervention students exhibited a signiicantly higher odds ratio for the performance of muscle-strengthening exercises on at least one day per week and for the achievement of the recommended levels of this practice. However, more pronounced efects were observed only when the efectiveness results using data collected from the students who had participated in the entire study were analyzed.
Table 4. Postintervention efects of the Saúde na Boa project on the physical activity indicators of public high-school students in Florianopolis (State of Santa Catarina) and Recife (State of Pernambuco) in 2006.
Variables Active commuting (≥1 day/week)
Active commuting (≥5 days/week)
Muscle-strengthening exercises (≥1 day/week)
Achievement of the recom-mended levels of
muscle-strengthening exercises OR CI 95% p-value OR CI 95% p-value OR CI 95% p-value OR CI 95% p-value Efectiveness (intention-to-treat)
Control 1.00 0.005 1.00 0.005 1.00 0.001 1.00 0.001 Intervention 1.55 1.14; 2.10 1.69 1.29; 2.22 1.37 1.04; 1.79 1.62 1.21; 2.17 Efectiveness (collected data)
Control 1.00 < 0,001 1.00 < 0,001 1.00 0.01 1.00 0.001 Intervention 1.97 1.38; 2.82 1.74 1.32; 2.29 1.42 1.08; 1.87 1.71 1.28; 2.29
Notes: Odds ratios (OR) and respective 95% conidence intervals (95% CI) were adjusted for gender, age, ethnicity, employment status, and school location. For active commuting (≥1 day/week), the analysis was baseline-adjusted due to the signiicant diference between the control and intervention groups.
In Table 5, considering the intention-to-treat results and the collected data, the efectiveness was assessed by comparing the efects of the inter-vention on the stages of behavior change in the control and interinter-vention groups. For the intention-to-treat results, students who participated in the project exhibited a greater probability of achieving the stages of ac-tion and maintenance, compared with students in the precontemplaac-tion stage. Similar results were observed when data only from students who had completed the study were analyzed.
Table 5. Postintervention efects of the Saúde na Boa project on the stages of change in physical activity behavior among public high-school students in Florianopolis (State of Santa Catarina) and Recife (State of Pernambuco) in 2006.
Variables
Contemplation vs. Precontemplation
Preparation vs. Precontemplation
Action vs. Precontemplation
Maintenance vs. Precontemplation ORa CI 95% p-value ORa CI 95% p-value ORa CI 95% p-value ORa CI 95% p-value
Efectiveness (intention-to-treat)
Control 1.00 0.213 1.00 0.519 1.00 0.003 1.00 0.009 Intervention 1.40 0.82; 2.38 1.19 0.70; 2.00 2.18 1.30; 3.68 1.94 1.18; 3.19 Efectiveness (collected data)
Control 1.00 0.196 1.00 0.500 1.00 0.005 1.00 0.005 Intervention 1.43 0.83; 2.44 1.20 0.71; 2.03 2.13 1.25; 3.60 2.07 1.25; 3.43
Efectiveness of an intervention in physical activity Del Duca et al.
DISCUSSION
his study indicated that the Saúde na Boa project was efective in increasing the number of students who actively commuted to and from school and/or work, performed muscle-strengthening exercises, and achieved a more ad-vanced stage of adherence to physical activity practices. To date, the authors are not aware of the existence of other studies on physical activity indica-tors using randomized and controlled interventions in Brazilian teenagers. he school is a privileged environment for discussions of health-related topics involving children and adolescents, including discussions concern-ing physical activity; this is where young people spend most of their week and where the social functions of education in its diferent domains are assigned. herefore, it is expected that the school environment efectively
helps young people adopt an active and healthy lifestyle13. According to
Costa et al.14, this inluence occurs mainly through the creation of
environ-ments conducive to physical activity and the incorporation of didactic and pedagogical approaches into the school curriculum.
In fact, several reports worldwide have indicated the efectiveness of
educational practices aimed at increasing physical activity7,15. A recent
systematic review of existing interventions in Latin America has identiied four strategies for promoting physical activity at school: curricular changes in physical education classes, adequate infrastructure and training of school staf, provision of adequate equipment and supplies, and directing
of actions according to the proile of the target population7. Importantly,
such strategies were used in the Saúde na Boa project9.
Efect on active commuting
Previous research has revealed important efects of active commuting on
health16,17, including increased levels of physical activity18, an improvement
in itness and health,19 and the minimization of problems such as traic
congestion and the environmental pollution and noise derived from the
use of private transportation20. In the present study, the practice of active
commuting was increased both on ≥ 1 day per week and on ≥ 5 days per week in the intervention group, compared with the control group. Con-sidering the odds ratio, these values corresponded to an efect of 1.66 and 1.45, respectively. In the analysis separated by groups, there was a decrease in active commuting in the control group on ≥ 5 days per week (–6.8%).
Commuting is considered an essential element of physical activity and has been used in intervention strategies to promote an active lifestyle among children and adolescents. As such, commuting to school is a be-havior that enables the adoption of a daily routine among young people. Although the average time spent on active commuting to school/work (15 to 30 min) was below that recommended for physical activity, this practice contributed to an increase in the total amount of physical activity, with a weekly expenditure of 955 kcal (considering a distance of 1.9 km with a
A review study has reported that the physical environment (e.g., the pres-ence of open spaces, parks, and recreational facilities) has a positive efect on
active commuting22. Another recent review reported the implementation of
several interventions focused on active commuting to school. Most of these interventions used a quasi-experimental design and were conducted with elementary school students in the United States, Australia, and the UK. Other studies created interventions with the participation of schools, parents, and the community, and reported an increase in active commuting in the range
of 3% to 64%. However, 6 of the 12 studies reported only small efects23.
In the present study, the main strategies for active commuting com-prised the installation of bicycle racks, bicycle rales, and the dissemination of informational material to motivate the students to adopt this behavior. Other initiatives that have had some success, including “Walk to School” and “Safe Routes to School”, were based on campaigns, speciic actions, and events that adopted incentives to encourage active commuting to school (www.iwalktoschool.org) as their main goal. In fact, changes in the physi-cal environment coupled with incentive campaigns tend to contribute to an increase in active commuting to school.
Efects of intervention on the practice of muscle-strengthening exercises
he current recommendations for physical activity have devoted a speciic section to strengthening exercises. hese recommendations specify that activities for the strengthening of muscles and bones should be performed by children and adolescents (5 to 17 years old) on at least three days each week, and by teenagers (18 to 19 years old) and adults at least two days perweek.11 he regular performance of muscle-strengthening exercises among
young people can reduce cardiovascular risk, promote weight loss, increase bone density, enhance psychological and social well-being, improve motor
skills, and reduce the incidence of sports-related injuries24.
he Saúde na Boa project efectively increased the number of physical exercise practitioners and enabled students to achieve the recommended muscle-strengthening exercise levels, in comparison with the control group. However, the authors found no other reports of interventions to encourage physical activity in schools that have analyzed the practice of strength exercises. his indicates that, although this type of exercise is important and strongly recommended, little attention has been devoted to its incentive and monitoring.
Efects on the stages of change in behavior
Monitoring the stages of change in physical activity behavior in teenagers is essential for an assessment of the levels of awareness of the practice. In terms of change in physical activity behavior, the Saúde na Boa project evoked students to transition from the inactive stage to the physically active stages. Moreover, the number of students who achieved the action stage postintervention (20.2%) was higher than that found in a previous
Efectiveness of an intervention in physical activity Del Duca et al.
Speciic actions to encourage active commuting, in addition to those cited, may have contributed to the increase in physical activity during lei-sure time. Among these, we highlight the delivery of physical activity kits, special weekend sports events, such as hiking and cycling, and lectures for teachers, technicians, students, and parents/guardians.
As reported by Dumith et al.26 in a literature review, comparative
analyses of indings from similar studies that have investigated the stages of change in physical activity behaviors may not be possible because most of these studies were cross-sectional, which precluded an evaluation of the temporal continuity of these behaviors.
Strengths and weaknesses of the study
Although the applied questionnaire has been evaluated on the basis of its psychometric properties, the collection of data through a self-report study may result in inaccuracy, particularly in behavioral data such as those involving physical activity. However, we believe that the repeatability of the data collection methodology for the control and intervention groups has minimized potential biases in data comparison. In addition, the oc-currence of school strikes and protests (over diferent periods) in both cities during the study led to the application of the school interventions over distinct periods. Nonetheless, the adequate amount of time devoted to each intervention and the adaptation of the study to the peculiarities of each city should have minimized any season-related problems.
he strengths of the study include the performance of randomized and controlled interventions, the selection of students who were enrolled in evening classes and were more exposed to physical inactivity, and the inclusion of physical activity variables that had not been adequately ad-dressed during previous interventions.
CONCLUSION
he Saúde na Boa project efectively increased active commuting, the prac-tice of muscle-strengthening exercises, and the status of physical activity. In addition, our results reinforce the need for the planning of interventions considering sociodemographic characteristics. In this sense, intervention strategies targeted to high school adolescents are attractive targets for the promotion of physical activity.
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Efectiveness of an intervention in physical activity Del Duca et al.
Corresponding author
Giovâni Firpo Del Duca Universidade Federal de Santa Catarina
Campus Universitário Reitor João David Ferreira Lima.
Caixa Postal 6510.
Coordenadoria de Pós-Graduação em Educação Física.
Bairro Trindade, Florianópolis, Santa Catarina, Brazil
CEP 88040-900.
E-mail: gfdelduca@gmail.com
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25. Oliveira N, Barros M, Reis R, Tassitano R, Tenório M, Bezerra J, et al. Estágios de mudança de comportamento para a atividade física em adolescentes. Motriz 2012;18(1):42-54.
